Institutions of care, moral proximity and demoralisation: The case … 2015.pdf · 2015. 8. 25. ·...

Original Article

Institutions of care, moral proximity anddemoralisation: The case of theemergency department

Alexandra Hillman

School of Social Sciences, Cardiff University, 10 Museum Place, Cathays, Cardiff CF103BG, UK.E-mail: [email protected]

Abstract This article draws on concepts of morality and demoralisation tounderstand the problematic nature of relationships between staff and patients in publichealth services. The article uses data from a case study of a UK hospital EmergencyDepartment to show how staff are tasked with the responsibility of treating and caring forpatients, while at the same time their actions are shaped by the institutional concerns ofaccountability and resource management. The data extracts illustrate how suchcompeting agendas create a tension for staff to manage and suggests that, as aconsequence of this tension, staff participate in processes of ‘effacement’ that limit thepresence of patients and families as a moral demand. The analysis from the EmergencyDepartment case study suggests that demoralisation is an increasingly important lensthrough which to understand health-care institutions, where contemporary orga-nisational cultures challenge the ethical quality of human interaction.Social Theory & Health advance online publication, 3 June 2015;doi:10.1057/sth.2015.10

Keywords: demoralisation; emergency medicine; institutions of care; moralproximity

The online version of this article is available Open Access

Introduction

This article develops Bauman’s (1989, 1990, 1991, 1994) theories of morality andproximity and Fevre’s (2000, 2003) theory of demoralisation to explore theincreasingly problematic nature of relationships of care in public health services.There have been a number of recent cases in the United Kingdom in whichvulnerable people have been failed by the institutions that exist to care for them:the most emotive and controversial being the scandal that emerged following the

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revelation of gross institutional negligence within Mid-Staffordshire NationalHealth Service (NHS) foundation trust which resulted in many unnecessarydeaths and a great deal of suffering for patients and families (see Francis Report,2013). This scandal compounded reports highlighting the lack of basic care,dignity and respect for older people in UK hospitals (Care Quality Commission(CQC), 2011; Health Service Ombudsman, 2011).

The problem, that this article seeks to address, is what is the explanation forsuch a lack of care in the NHS? Popular propositions tend to focus on the moralityof individuals: the most prominent example within the NHS is the contemporarypathologisation of the ‘uncaring nurse’. This article offers an alternative to thepathologisation of the individual. By drawing on data derived from a case studyof a UK emergency department (ED), this article highlights the increasinglyproblematic nature of the interactions that occur between staff and service users.These interactions are situated in their organisational context, to show how theyare partly produced in response to the institutional structures and systems ofNew Public Management (NPM).

Public institutions of care, like the NHS, embody multiple and often competingsets of values relating to their purpose in serving the community. For example,health services may abide by a commitment to patient choice, a commitment thatmay have the potential to reduce care quality (Mol, 2008); or, services may bebuilt around an ethic of care that could inadvertently compromise an ethic ofjustice (Hoggett, 2006b). Such dilemmas and conflicts are further complicated byattempts, particularly from the previous New Labour government, to depoliticisepublic institutions, to ensure impartiality, fairness and a focus on ‘what works’(Clarke et al, 2000). These attempts privilege technical aspects of providinggoods and services and can result in the commodification of relationshipsbetween care providers and service users, hollowing out their moral and ethicalmeaning (Hoggett, 2006a). Finally, there has been an intensification across thedeveloped world of systems and procedures that seek to manage risk in publicinstitutions by limiting individual discretion in decision making in favour ofritualised tasks, performance targets and protocols (Checkland et al, 2004;McDonald et al, 2006; Brown, 2008; Brown and Calnan, 2009; Heath, 2010).Academic commentators have grouped these multiple and complex develop-ments under the label NPM. NPM essentially adopts private sector formsand practices and places them at the heart of state sector service delivery(Du Gay, 2000; Pollitt and Bouchaert, 2000; Dent et al, 2004; Cooke, 2006;Hoggett, 2006a, b).

For the NHS, these developments have been particularly dramatic. In recentyears the NHS has experienced fundamental change, not just in relation to themanagement of risk and rationalisation, but also because of increasing levels ofprivatisation (Pollock, 2005), most recently endorsed in the 2012 Health and

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Social Care Bill under the guise of ‘re-commodification’ (see Scamber et al, 2014).The impact of such change on NHS practitioners has been to generate new,distinctively managerial responsibilities that, some commentators suggest, shiftthe responsibility for the distribution of increasingly scarce resources away fromgovernments and onto clinicians and, in some cases, patients themselves(Maruthappu et al, 2010). The ED is a focal point for political and public concernover NHS provision. Its unique position as both a service open to the communityand a gatekeeper to acute hospital beds means that gaps in service provision, andthe limited capacities to meet demand throughout the NHS, have come to berepresented by the huge increases in the numbers of people arriving at the doorsto the ED. This year saw many departments reach breaking point, with somedeciding to close their doors on the grounds of patient safety (Osborne, 2015).It is therefore particularly poignant that the setting of the case study presented inthis article is an ED, where the effects of NHS organisational change are intenselyfelt, politically sensitive and publically scrutinised.

Alongside the academic commentary on NPM systems, the sociology ofmedicine has provided further evidence for how these ‘institutions of modernity’(Bauman, 1994; Heath, 2010) in the NHS have had dysfunctional effects on theorganisation and delivery of health care (see, for example, Alaszewski, 2006;Waring, 2007; Hillman et al, 2013). What is so far missing in both sets ofliteratures (the commentary on NPM systems or medical sociology’s challenge tothe changing political and organisational landscape in the NHS) is a directutilisation of theories of morality and demoralisation to better understand theincreasingly distorted and dysfunctional nature of the relationships betweenservice providers and service users. There are, however, key pieces of work thathave highlighted the relationship between values, ethics and organisationalcultures. Menzies-Lyth’s (1988) classic study, for example, shows the unin-tended consequences of institutional procedures developed to defend againstwhat she describes as the essential anxieties inherent in nursing tasks including:the splitting up of the nurse–patient relationship, the depersonalisation of caringwork, the reduction of discretion in decision making and a redistribution ofresponsibility for caring tasks. Her findings remain relevant to nursing care today(see Tadd et al, 2012; Hillman et al, 2013). This article contributes to the ongoingstudy of the changing nature of caring relationships in health-care work, byfocussing specifically on the ways staff respond to their working environment.In particular, this article demonstrates how this response impacts upon staff’sability to draw upon moral categories in their relationships with service users.

An important body of work (see Hoggett, 2006a, b; Hoggett et al, 2006), thathelps contextualise the changing nature of these relationships, has highlightedthe complexity of competing frames and networks (for example, institutional andbiographical) that inform how those employed in public services relate to their

Demoralisation: The case of the Emergency Department

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work and the people they serve. By utilising ideas of morality and demoralisa-tion, this research explores the presence and/or absence of a moral componentwithin these competing sets of values. In particular, it questions if, how andwhen particular value systems become privileged over others. For example, whatare the conditions in which the values of the institution takes precedence overservice users?

To tackle these questions, this article explores Bauman’s (1989, 1990, 1991,1993) concepts of morality, moral proximity and practices of effacement tointerrogate the interactions between staff and patients and to situate them withinbroader cultures of care. Bauman (1990) describes morality as the automaticresponsibility for another person that occurs as a result of their proximity.Proximity impacts upon moral responsiveness (Walker, 1998) and is thereforeconstituted through relationships; these need not necessarily rely upon physicalor emotional proximity but require some knowledge of the other person that willelicit a response. Bauman (1990, 1991) describes forms of social organisationthat, even with the occurrence of face to face contact, limit the proximity of theperson in ways that can restrict moral responsibility.

For Bauman (1990, 1991), it is not social organisation that is needed to tamethe natural moral inadequacies of human beings; it is modern society that createsthe means through which to limit proximity, creating a world where action ispossible without being underlined by the human capacity of moral regulation.Fevre’s (2003) demoralisation theory builds upon Bauman’s central claim, thatdevelopments in modern society provide the conditions for a loss of morality inthe shaping of our everyday lives. Fevre suggests that morality describes actionsthat arise from sensemaking based on categories of belief rather than knowledge.Without these resources we are only able to rely on guidelines from science or,increasingly, economic rationality. Fevre (2000, 2003) therefore provides avariation of Bauman’s argument by suggesting that modern society creates animbalance of sense-making resources available to people, setting the foundationsfor category mistakes in which people draw on the wrong resources to informtheir actions. Demoralisation therefore has two meanings: first, a stripping awayof morality or a reduction in moral actions and, second, a lost sense of purpose; itis both about morals and morale (Fevre, 2000). The increasing dominance ofrationality as an essential grounding for the delivery of health care (Ahmed andHarrison, 2000; Clarke et al, 2000) means that health services have come to begoverned by rational precepts of business economics that create multiple formsof sensemaking that exist in parallel to the resources of morality.

Following a brief account of the study, the remainder of this article is organisedinto four parts. The first part illustrates how processes of assessment in the EDcreate competing duties for staff. The second and third parts of the article –‘creating distance, limiting moral proximity’ and ‘re-establishing proximity’ – build

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upon this ethnographic context and set out theoretical ideas that developBauman’s concepts of moral proximity and effacement and show their relevancefor understanding contemporary institutions of care. In the final part, the‘Discussion’ – the article draws together the previous analysis to suggest a (re)conceptualisation of moral proximity as a social accomplishment and finally, thequestion posed at the start of this article (How might we explain the growingproblem of a lack of care in institutions such as the NHS?) is reconsidered in lightof these theoretical developments.

The Study

This ethnographic study of emergency medicine was carried out in a large innercity UK teaching hospital with a particular focus on the assessment, care andtreatment of older people. The project ran over four years between 2004 and 2008and received ethical approval from an NHS National Research Ethics Service(NRES) committee and research governance approval from the NHS trust takingpart. Participants of the study included medical staff of all levels from health-careassistants to the clinical director, patients, patients’ relatives or carers andmanagerial staff. All participants were given a pseudonym at the point of theirfirst entry into fieldnotes. A separate document, accessible only to the researcher,kept a record of all participant names and their attributed pseudonym. The studycomprised of 250 hours of observations in the ED and 35 qualitative interviews.The examples presented in this article are taken from fieldnotes of observations.

Observations were carried out across each distinct area of patient care withinthe ED and visits were arranged to cover the seasons, the days of the weekand times of the day and night. The most intense periods of observation werecarried out during the Winter months of 2006 and 2007 (November, Decemberand January), and the Summer of 2007 (May, June and July). During theseperiods, visits to the ED were once or twice weekly. Timings of observationsmirrored the shift patterns of staff, both doctors and nurses. The observationswere flexible and unstructured but loosely took on two approaches: patientswere tracked from their initial assessment to eventual admission or discharge;members of staff were shadowed while working their shifts. The meanings of theactions and interactions observed were further elicited and explored throughboth formal and informal interviews with staff and patients.

The 250 hours of observation accumulated over the course of the studyincluded the tracking of 50 older patients (over 65) through their assessment inthe ED. Although the focus of the study was on the experiences of older people,the assessment and treatment of patients under 65 became a central part ofunderstanding the culture of the ED and older people’s place within it. The



observations focussed on the means with which staff accomplished categorisingpatients for priority of treatment, the negotiations that occurred during theseclinical encounters and the meanings of these interactions for staff and patients(and their relatives). Observations also focussed on the organisational cultures ofemergency medicine such as processes of clinical governance and professionalpractice, the socio-spatial organisation of the department and the people andmaterials within it, and formal and informal staff hierarchies and networks.

Both fieldnotes and interview transcripts were analysed thematically and thiswas undertaken simultaneously while carrying out fieldwork. This meant thatemerging issues, such as the categorising of patients for priority of treatment,could be read and interpreted alongside broader institutional concerns ofthroughput and the rationalisation of resources. The researcher’s position asobserver was reflected upon to identify influences on the encounters theyobserved. For example, decisions over when to observe, how to stay attuned tothe wishes of those being observed and when to withdraw altogether werecontinually negotiated in the field between the researcher, the patient and thestaff participant. The ED is a fast paced environment, with strict rules andlimitations on who can be where, when. It was therefore paramount that theresearcher found a role, in each area of the department, which afforded them adegree of legitimacy, while enabling them to remain an observer. This ofteninvolved being enroled as a ‘student’ or ‘assistant’ by the staff themselves. Theseethical and practical negotiations in the field were recorded in the fieldnotes toshow how they informed the interpretation of meaning in the data.

The data collected together within themes were checked for the consistencyand validity of interpretation. The constant comparative method (Silverman,1993) was used to check the relationship between concepts and to build commonthemes. Initial analysis was discussed with practitioners and patients informallyduring fieldwork visits as a means of ‘respondent validation’ (Bloor, 1978).

The juxtaposition of dutyThe focus for the analysis presented in this article is on the interactions thatoccur at the point of access to emergency medicine. The initial negotiations overaccessing the ED occur during triage, a system set up to prioritise patientsaccording to clinic need. Triage is the process in which the contestation andnegotiation over accessing the resources of emergency medicine is mostintensely governed (Gibson, 1978). Triage is a perfect description of Fevre’s(2000) ‘mixed field’: it organises patients according to categories of priority;priority is determined according to a complex interaction between clinicaljudgement, professional interests and the perception of patients’ moral worth(for examples of patient categorisation, see Roth, 1972; Hughes, 1976; Latimer,1999; Hillman, 2014).

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Owing to its physical and symbolic location between publics in need and acutein-patient care, this section of the ED is particularly mediated by institutionalconcerns over increasing demand and efficient patient throughput. For example,‘the patients’ as a group to be assessed, treated and discharged have a significantpresence for those working at the point of access to the ED. As a result, there is amore explicit responsibility for staff working in triage to organise and account for‘the patients’ as well as assessing and treating individuals.

All patients are automatically logged on to an interconnecting computersystem called ‘Jonah’. Jonah provides a checking system for every ED patient atall stages of the assessment process. This information can be called upon to checkthe location or status of a patient, monitor staff performance or to ascertain theworking practices of the unit as a whole, as one of the nurses explained to me:

The system aims to ensure that everyone is made responsible for workingefficiently ‘cause with this, everyone is accountable ‘cause it knows at alltimes who’s responsible for each patient in the department. (MinorInjuries, Winter 2006)

Such practices engender social adjustment in individuals according to theguidelines set out by the institution; adjustments and actions that can then be ‘re-described as evidence of their accountability’ (Strathern, 2000, p. 4). Theseadjustments in behaviour shift the focus of staff’s attention so that they attend tothe tool itself, rather than the patients it supports (Coughlan, 2006).

The production of the initial assessment form, that is added to and developedby staff to form the patient record, contributes to the way patients are ‘inscribed’(Latour, 1986). When doctors ‘collect patients’, they actually collect the two-dimensional material inscriptions of patients produced through the patientrecord, not the ‘three-dimensional subject’ (Mort et al, 2003, p. 273). Materialsand systems through which patients are inscribed also exist among standards,protocols and guidelines that shape how staff interact with patients duringprocesses of assessment:

In a quiet moment I notice a red file on one of the desks called ‘NationalTriage Presentational Flow Chart’. This file seeks to provide symptom signsthat will allow for a more accurate placement of patients into appropriatetriage categories so that, as stated on the inside cover of the file, ‘the moresevere pathologies are appropriately triaged’. Inside the file are plasticwallets containing individual flow charts for specific presenting problemsthat a patient may attend A&E with. These flow charts ask a series ofquestions and provide possible responses. By following the responses apatient may give through this flow chart, a triage category is reached.(Triage, Winter 2006)



These tools represent what Ahmad and Harrison (2000) call scientific-bureau-cracy in which clinicians rely upon protocols and guidelines to rationaliseprocesses of assessment according to external evidence. Tools for supportingclinical decision making create a further means through which staff perceivepatients differently. The application of this technology effectively reducesthe ‘mixed field’ to one form of sensemaking (Fevre, 2000) that reduces thepossibility for staff to build upon their embodied, tacit knowledge and thosemore qualitative skills of interpersonal communication (Nettleton et al, 2008) inwhich patients’ personhood remains. That is not to suggest that the techniques ofclinical governance create a workforce acting only according to the values ofscientific-bureaucracy (which is itself only one of many competing, and oftencontradictory, set of institutional values). Staff interpret and attach meaning togovernance processes in a multitude of ways that may be contrary to theirinstitutional intentions (Brown, 2011).

The purpose of providing this description is to show how relationships of careare mediated by technologies of audit that embed institutional concerns ofrationalisation and efficiency into staff’s daily decision making. Contradictionsarise at these sites of negotiation, where the problem of caring for ill people isjuxtaposed with the responsibility to account for one’s actions according to suchinstitutional concerns. The organisation of ED work, therefore, creates thepotential for losses in moral proximity between staff and their patients, so thatstaff become demoralised and patients’ de-humanised. The next section illus-trates the mechanisms through which staff cope with competing duties andshows how these coping mechanisms both respond to and sustain the ED as ademoralised social space.

Creating distance, limiting moral proximityStaff working at the point of access to the ED are burdened with responsibilities.It is the responsibility of staff, particularly nursing staff in this area, to not onlytreat and care for patients but to manage them. They must manage ‘the patients’both for physicians, who expect to collect patients pre-assessed with a categoryof priority assigned, and for the institution, that requires patients to be orderedand tracked through the ED system on the basis of efficiency targets and practicesof accountability. Allen (1997) has suggested that nurses can usefully be thoughtof as boundary workers: their work is located among patients, with otherprofessionals and providers and their competing understandings of illnesses andepistemologies of treatments, needing to be interpreted and co-ordinated. In thecase of the ED, this boundary work can be extended to incorporate theinstitutional logics of accountability and efficiency.

In order to cope with competing duties, staff participate in practices ofeffacement (Bauman, 1991) that can render patients and families ‘faceless’, thus

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limiting their presence as a moral demand. Practices of effacement are aconsequence of staff’s potential moral distress from what Peter and Liaschenko(2004) describe as the perils of proximity. They argue that proximity to patientscompels staff to experience their moral responsibilities so that constraints to thatresponsibility become morally distressing. The responsibilities of staff to managepatients according to institutional concerns can mean that acting on the basis of amoral response is challenged. Processes of effacement therefore create anecessary distance and detachment for staff, reducing the potential for moraldistress or anxiety (Menzies-Lyth, 1988).

The extract below is taken from a conversation between two triage nurses:

On this occasion there was a nurse I had not met before in charge of minorinjuries. Nurse Harbury. I introduce myself to her and again describedbriefly my research interests. She was not unfriendly, but quite disinter-ested. After getting despondent with patients congregating in complaint atthe door to assessment room 1, where she was based, she growls at a fellowmember of staff, an older nurse called Sister Smith.

They have a chat about ‘what this job does to you after a while’,

She claims, ‘doing this job will drive you mad, you end up hating thepatients’ She looks at me, the conversations seems verymuch for my benefit.Sister Smith responds by saying ‘you’re too young to be feeling like that…youshould be smiling sweetly at the patients still’. (Minor Injuries, Summer 2006)

Owing to both the physical presence of patients congregating in the waitingarea, and the specific role of ED staff working in triage to assess, assign categoriesand process patients, ‘the patients’, as a faceless entity to be managed has greatersignificance. As Bauman (1990) notes, as soon as the other is cognized, theybecome an object causing a fundamental break in proximity. As a consequenceof this effacement, patients can become reduced to a collection of parts orattributes that can be labelled, ordered and quantified.

Nurse Harbury explains that ‘Doing this job will drive you mad’. Thisstatement occurs following a number of incidents that occur at the door toassessment room one, a place in which the experience of working within acontinually contested domain (Hoggett et al, 2006) is intensely felt. It is a placewhere ethical dilemmas and conflicts arise and where the demands upon staff tomanage resources and adhere to processes of accountability are high. This isbecause of staff’s unique role in managing the flow of attending ED patients andtheir admittance onto acute hospital wards. The multiple available categories forsensemaking (Fevre, 2000) in these incidences are therefore squeezed out, sothat staff are compelled to act according to organisational priorities that, at leastmomentarily, become privileged. The madness Nurse Harbury refers to is



therefore the feelings that derive from the detachment and the distortions thatoccur in staff’s relationships with their patients. What is it that is ‘hateful’ aboutthe patients? In this context, the nature of the relationship between patients andstaff is combative, patients become an enemy. It is not individual patients thatthe staff ‘hate’ but the patients as a group. The reducing of patients to ahomogenised group in opposition – the patients – is further exacerbated by theconcerns staff have over patient complaints and litigation:

When I arrived in the triage room, a couple of the nurses are talking. Theyacknowledge me and go back to their conversation. They are discussing acolleague who would seem to have been implicated in an investigation of apatient complaint:

Nurse John: The problem is that it should never have happened that Sue(a junior nurse) was assessing the patient on her own. It’s her word againsthis now.

Nurse Jane: (looking over at me) people would think it’s us against themthe way we talk. (Triage, Winter 2007)

This example was one of many in which staff discussed the need to protectthemselves against ‘the patients’. The relationship between risk, trust and theculture of blame, and its ramifications in health-care settings, has received muchsociological attention (Brown, 2008; Jones, 2009; Locke, 2009; Petrakaki et al,2014 to name a few). Such a culture shifts value away from patients as persons toadhere instead to institutional logics that protect staff’s position within theinstitutional culture. As a result, both patients and staff are rendered less thanfull moral subjects. The imbalance and reduction of sense-making resources(Fevre, 2000) available to staff to make decisions in their daily work hollows outthe moral value that can be attached to it and subsequently distorts theirrelationships with patients; they become demoralised.

According to Bauman (1989), for people to be rendered less than full moralsubjects, proximity must be replaced with social distance that can only occurthrough a physical or spiritual separation of the other. In the case of the ED, it isthe permeation of instrumental rationality in the form of systems of account-ability, resource management and institutional risk (Power, 1997) of litigation,into the actions and decision making of frontline staff that works to neutralise theethical dimension of clinical work and allows for the spiritual separation thatBauman describes. The extract below illustrates the way one member of staffmaintains such a separation:

An elderly woman, Mrs Preston who is in her 80s enters nursing assess-ment room one. She has a bloody nose and mouth and is holding ahandkerchief to her face to try and stop the bleeding. She is slightly

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dishevelled and seems a little shaky. She is helped in by another womanwho looks slightly younger than Mrs Preston. Nurse Harbury motions forher to sit down on the chair in front of her as she says hello. As Mrs Prestonis sitting down she explains to the nurse that she fell down in the park.

Nurse Harbury: Do you remember everything?

Mrs Preston: What do you mean everything? Uh, yes I think so.

Nurse Harbury: What happened after you fell, do you remember?

Mrs Preston: I remember being in a neighbour’s house…

Nurse Harbury: (Interrupts) So you remember being on the floor?

Mrs Preston: (Tentatively) Yes

After Nurse Harbury had finished examining Mrs Preston she asks her ifshe would like to clean up a bit at the sink, as she has quite a lot of bloodover her face. Her friend looks surprised but helps Mrs Preston to the sinkand they struggle together to attend to her bleeding face and mouth. Whenthey are finished, Nurse Harbury looks up from her notes and hands her adressing to hold on her face until she can get her stitches done. (MinorInjuries, Summer 2007)

Significantly, Nurse Harbury does not attend to Mrs Preston’s face. This isparticularly poignant as a person’s face is symbolic of their personhood andtherefore the intimate care and attention involved in the process of cleaningfacial wounds may break the possibility of moral distancing.

The shifting of patienthood on the basis of inscriptions that constitute patientsin particular ways (Mort et al, 2003) is a significant method through whichpatients can be transformed into an other. The permeation of rationalisation intothe work undertaken by staff working at the point of access to the ED, in the casebelow, constitutes the demotion of the patient from a full moral subject to a‘faceless’ entity characterised by specific attributes:

Following some difficulty with a mentally ill patient who had refused toleave the A&E department, there was a young woman with a cut on herankle waiting to be seen by a doctor who the nurses believed to be a self-harmer. She has been waiting a considerable amount of time and hadrepeatedly knocked on the door to the assessment room, which added tothe annoyance of the staff who had been ignoring her knocking.

After the fourth or fifth time, Sister Smith opens the door and said Look I’mwith a patient at the moment. I will open the door when I’m ready to and notbefore.



The young woman was clearly frustrated and responded by saying that shehad been told to knock on the door by the reception staff. Sister Smith doesnot call the patient when she has finished dealing with the current patient.An hour later the woman left. (Triage, Winter 2006)

The nurses’ suspicions that this woman had cut herself meant that she was leftto wait considerably longer than other patients with a similar injuries. Thisincident responds in part to the competing sets of values and dilemmas that staffmust negotiate in their relationships with service users. The value of compassionand care towards this patient in need is complicated by the responsibility towardsall patients needing treatment and care. There are however complicatingvalue systems at play in this example that reflect both professional andinstitutional interests. As has been shown in previous work (Jeffrey, 1979;Dingwall and Murray, 1983), those patients attending the ED with problems theyare deemed to be responsible for are perceived negatively by staff and oftenexperience forms of punishment including longer waiting times, fewer tests orexaminations and sometimes even refusal of treatment. The problem this girlattends with is transformed into an attribute that effaces her. Not only is she partof the patients as a group in opposition, but she is a ‘bad’ patient. Theseprocesses of effacement are sustained by the culture of rationalisation in the EDtowards the treatment of acute trauma patients. Such a culture shapes staff’sperceptions of patients so that specific traits attributed to them (Armstrong,1983) can become tools enabling staff to distance themselves from patients’personhood.

To act upon such specific traits allow the staff to avoid moments that mayinduce morally significant effects. The attribution of moral categories is rarelygiven as a response to patients’ personhood; rather these categories provide themeans through which patients can be reduced to types. The following twoextracts illustrate this phenomenon:

After lunch there were a few junior doctors gathered in Assessment roomone, talking about what shifts they were on. They talked about how tiredthey were and how they weren’t able to do anything other than sleep andwork.

One of the male doctors, Doctor Glass turned to me and asked, ‘so who areyou, are you a student? I replied by saying yes, but not a medical student.I told him about my research, in the same way I had described it to NurseMorris, that I was interested in Older patients who attend A&E, as althoughthey are in need of emergency medical care, their problems are often morecomplex and may relate to chronic conditions and their social circum-stances as well as their emergency medical needs. Dr Glass responded with:

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So you’re interested in the social. You’ll wanna go to the trolley bay. That’swhere the social go. They’re what the cynical, depressed medical studentscall crap (he looked at the others and laughed and they smiled and laughedwith him).

Whilst describing my research to another doctor in the assessmentroom, Nurse Price who had become a useful source of informationwhen on duty, told me that what I am really interested in are the‘a-copias’. I look confused and he goes on to explain that in medicalterminology every word that begins with an ‘a’, the ‘a’ refers to without/nothing and so an ‘a-copia’ is someone who can’t cope. He chuckles andsays it’s probably made up but it sounds good doesn’t it? (Triage, Winter2006)

These extracts illustrate how perceptions of patients’ identity or personhoodare re-constituted as moral categories or traits that define patients as settypes. These moral categories are constituted according to professional andinstitutional interests. Professional interests favour cases that are novel andprovide possibilities for clinical intervention that necessitates skill and technol-ogy (Becker et al, 1961; Jeffrey, 1979). ‘Acopias’ are those deemed unable tocope, who are deemed to have little or no demonstrable clinical problem.‘Socials’ are deemed to have problems that are a direct result of their socialcircumstances, (this can include their age) which negates their clinical needs.And the ‘crap’ refers to those cases deemed to be minor or mundane. Thesepatients are attributed such negative labels because they do not provide ‘goodclinical materials’ (Latimer, 2000) for staff to demonstrate clinical competency.The value (or lack of value) attributed to these patients is therefore, in part, aresponse to professional interests.

Along with professional interests, relationships between staff and patients arealso informed by the institutional logics of emergency medicine. These logicsnecessitate that patients have a quick and measurable response to clinicalintervention (so that they fit better within performance targets and efficiencytools) and fit the increasingly rationalised definition of the ED patient: thesufferer of an acute trauma (Hillman, 2014), thus re-establishing a definition ofemergency medicine as a distinct speciality, ensuring greater status, power andpotential for resources. For staff, these labels not only respond to the culture ofmedical work and the institutional concerns of emergency service provision,they also provide a means with which to efface those patients who mayotherwise remain present as a moral demand. The proximity of the ill olderperson waiting on a trolley for an acute bed, for example, is instead reduced toanother ‘social’who ‘shouldn’t be here’, lessening the potential for such patientsto induce moral distress.



Re-establishing proximityThe previous examples have shown how staff engage in practices thatdistance themselves from their patients as full moral subjects. However, thereare moments when this distancing is challenged and proximity restored. Thefollowing example describes a situation in which Sister Brown’s practices ofeffacement are challenged:

The first patient I observed was a sixty six year old woman, Mrs Jackson,who came in for a twisted ankle and foot. She explained that shehad done it while getting out of her son’s car at the cinema the night before.

There are no obvious signs of swelling or bruising but the woman appearsto be in a lot of pain.

Mrs Jackson: Honestly, I’ve been crawling around the house on my bum… Ican’t put any weight on it at all

Sister Brown: Well, just to warn you. If your foot isn’t broken you’ll have toput weight on it and walk on it properly otherwise it won’t heal.

Later, following an ex-ray of the patient’s foot ….

Sister Brown: It’s not broken so you’ll need to take regular pain relief. Thebest is to take a combination of paracetomol and anti-inflammatory whichyou can take together three times a day. For the first couple of days elevate it,put an ice pack on it but make sure its wrapped in something don’t put itstraight on the skin and make sure It’s for no longer than 10minutes in anyhour. After a couple of days start trying to walk around on it.

Mrs Jackson: What about driving?

Sister: I wouldn’t drive because with the pain you’re having you won’t havefull control of the car

Mrs Jackson: (beginning to look upset) My husband’s in a care home yousee and I drive to visit him a couple of times a day.

Sister: What about your son who brought you in today, does he drive, couldhe not take you?

Mrs Jackson: (getting more upset) He’s going back to London later today, hewas just visiting

Sister: (A little more sympathetic) Ah, oh dear. It makes life difficultdoesn’t it?

Mrs Jackson: (Begins to cry) How will I get to see him?

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Sister Brown comforts Mrs Jackson by putting her arm around her,Mrs Jackson immediately seems better in response to this gesture.

Mrs Jackson: I’ll just have to get taxis I suppose

Sister:Well after a couple of days the pain should have eased a lot, you couldtry driving then. (Minor Injuries, Summer 2007)

In this example Sister Brown initially remains distant to Mrs Jackson, seemingquite dismissive of her explanations of pain and ‘crawling around on her bum’.However, through Mrs Jackson’s sadness about the difficulties she will have inseeing her husband, Sister Brown begins to soften. The introduction of emotioninto the interaction between Sister and patient, along with the patient’s ownaccounting for her circumstances and her resolve to make the best of things – ‘I’lljust have to get taxis I suppose’ – begins to chip away at Sister Brown’s earlierattempts to keep Mrs Jackson at a distance and shifts the conditions of theirrelationship. Malone (2003) suggests three types of proximity in relation tonursing care: physical, narrative and moral. In order for moral proximity toendure, a physical nearness to the patient’s body and understanding of thepatient’s narrative are necessary so that the nurse may engage with the patient intheir particularity. In this case, Mrs Jackson’s story distinguishes her from ‘thepatients’ as a group, helping her regain her particularity and thus her personhood(Bauman, 1989).

The following example describes the last moments of a crisis in which a mancollapsed in the waiting area of the ED:

When eventually the nurses began to take him towards resus’ (theresuscitation room) the man managed to speak and asked if he was safe towhich Nurse Claire replied yes, we’re going to look after you don’t worry.He then asked am I going to die to which she replied No you’re not going todie, not while I’m here. Nurse Stuart then said ‘you’re definitely not going todie here. Nurse Claire: Far too much paper work for us. (Corridor betweenthe waiting area and resuscitation, Winter 2006)

Although this extract may seem cold and insensitive, the context wasrather different. The informality that such a joke engenders immediatelyalters the context of the situation so that the man’s panic subsides and he isreassured. Moral proximity and moral response is enabled through the nurses’re-configuration of the rational systems that have worked previously to distancethem from patients. The need to make an automatic response is essentialto maintain proximity and re-establish the response to the patient pre-cognition(to use Bauman’s term) or in parallel to cognition (to use Fevre’s idea of themixed field).



The important question to ask about this incident is: how is Nurse Claire ableto re-frame the institutional concerns of record keeping and accountability(too much paper work for us) to reassure this man? Perhaps the immediacy ofthis patient’s need means that the inherent anxieties of the nursing task(Menzies-Lyth, 1988) cannot be defended against through an adherence toorganisational processes and protocols. Instead, Nurse Claire responds directlyto the proximity of nursing work.

This subversion of the institutional priorities that shape staff’s experiences ofassessing and treating their patients is further exemplified in the extract below:

The National Triage Presentational Flow Chart file was used during anassessment of James, a young man who had attended A&E due to hishypo-glycaemia. Nurse Peters picked up the file and turned to the patientand said let’s try and get you through a bit quicker. After looking at thepresentation flow chart on diabetes, Nurse Peters filled in the triageassessment form. After the patient left the assessment room Nurse Peterslooked at me and commented that I did him a favour… tried to get him seena bit quicker. (Triage, Winter 2006)

In this example, Nurse Peters decides that this patient needs and/or deserves(values attributed to both clinical need and moral worth are likely to be at play)to be ‘seen a bit quicker’. Unfortunately, the background to this case, the takingof the patient’s history and the interactions between the nurse and the patient,were not observed, so the full context of the encounter is unavailable. Perhapsthe patient was able to present his case in a way that ensured him greater priority(Hillman, 2014), or perhaps Nurse Peter’s own personal history meant that heattached particular value to the needs and/or circumstances of this young man’sattendance (Hoggett et al, 2006). There are also many, diverse aspects oforganisational culture that inform staff decision making and make up whatHorlick-Jones (2005) describes as an ‘interactional matrix’. These include: localinformal hierarchies, professional conflicts and local habits and rituals in thecarrying out of caring tasks, all of which staff must negotiate in their dailyworking practices. The interplay of value systems that shape the actions anddecision making of staff in their relationships with patients is complex and beingsensitive to the context and contingencies of actions and decision making isessential to understanding how particular sets of values are able to takeprecedence.

In this case, once Nurse Peters attaches value to this man’s needs, over thevalues of institutional processes, he uses the file in the reverse way to itsproposed purpose. Nurse Peters decides upon the triage category that the patientwas to be placed in and subsequently works backwards in the flow chart in orderto present the correct signs and symptoms to legitimate this decision. As Berg

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(1992) similarly illustrated in his study of medical assessments, both patienthistories and examination data can be given more or less validity depending ontheir usefulness in determining the desired transformation.

Both Nurse Claire and Nurse Peters illustrate how staff utilise the tools andtechniques for clinical governance in unintended ways. The meaning attached tothese systems and their interpretation of them in their interactions with patientsmaintains proximity and makes it possible for patients to be present as a moraldemand.

Discussion

This article highlights the practices of effacement that staff undertake to copewith the tensions they experience between responding to patients as full personsand responding to institutional concerns of accountability, resource rationalisa-tion and the management of institutional risk. The article illustrates the variousstrategies through which the distancing of patients as a moral demand isaccomplished. First, the perception of patients as a group to be managed is animportant way in which patients become cognized (Bauman, 1990) and subse-quently objectified as a group in opposition. Second, when individual patientsattempt to make their claims distinct, as in the case of the young woman whowas believed to have self-harmed, staff respond to a negatively constitutedattribute, such as the patient being deemed responsible for the problem theyattend with. These traits are constructed according to professional interests andinstitutional concerns and potentially reduce patients’ personhood to a repre-sentation of this negative trait. The effacement of patients as full moral personsenables staff to act under competing pressures that also have the potential todeny or suspend their own status as moral beings.

It is the contention of this article that this space of demoralisation isaccomplished through the organisation of social relations within the ED. TheED is a space of demoralisation because staff are left with few alternatives but tomake sense of their experiences through the clinical, organisational and admin-istrative systems of classification that mediate patient assessments. Practices ofeffacement provide staff with a tool enabling them to cope with working in ademoralised environment. Such practices therefore both respond to and furthercreate a space of demoralisation. In recognising demoralisation as a socialaccomplishment, morality ceases to be understood as socially modular, distinctfrom everyday life. Instead, morality and moral actions are collaborativelyproduced; we reproduce or shift our moral understandings together, in manydaily interactions of social life (Walker, 1998). The problem of proximity and



staff’s responses to it are therefore both responsive to and constitutive of thewider organisational cultures in which they are embedded.

The article has provided three examples from the ED in which patients remainpresent as a moral demand and in doing so highlights the mechanisms throughwhich moral proximity is re-established. These examples are important to high-light that ED staff do not simply perform to institutional logics of efficiency andaccountability. This work, along with others (for example, Bolton and Houlihan,2009) attempts to move beyond the agency/control dualism in understandingthe relationship between health-care workers and NPM systems. Instead, theseexamples illustrate the potential for resistance and the multidimensionality in theways such ‘institutions of modernity’ (Bauman, 1994) are experienced andperceived by medical staff (Brown, 2011). While recognising the multiplicity ofstaff interpretation, in all three examples, staff are informed by the systems ofgovernance that mediate their work. Although staff act in contrast to the intendedpurposes of techniques of governance, they remain implicated in there continua-tion as significant determinants of social organisation. As a result, in order toaccomplish proximity, staff must both accommodate these systems of governancewhile at the same time make decisions that contradict their purpose.

To return to the problem posed at the beginning of this article: What are theconditions in which a lack of care in institutions like the NHS is able to endure?The case of the ED provides some useful insight. The examples show that theability of staff to draw on a morally grounded responsibility towards theirpatients is being challenged by the competing demands placed upon them. Forstaff to re-create moral proximity, their actions and interactions are necessarily inconflict with the ‘institutions of modernity’ (Bauman, 1994) that govern theirwork, institutions that are increasingly embedded in health and social careorganisations both in the United Kingdom and internationally (Schout et al,2011). In other words, the value of ethically informed care is increasingly absentfrom the moral community of health-care work (Peter and Liaschenko, 2004).To sustain a moral response to those seeking help through the NHS, staff mustactively resist the dominant cultures that shape their daily working practices.Furthermore, the enhancement of the moral and ethical orientation of caringwork, that comes from challenging these cultures, rarely results in reward orsocial recognition.

Bauman and Fevre’s theories of morality and demoralisation providesignificant insight into the ‘problem of care’ within the NHS. The value ofutilising such concepts lies in their capacity to highlight the social andinstitutional challenges to proximity (Bauman, 1991, 1990) and to moralcategories for sensemaking (Fevre, 2000) that form the pre-requisites formaintaining human social relationships that are responsive to the other. Theentrenchment of institutional concerns into the daily practices of clinicians

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and health-care workers can be seen not just in the ED but across many areasof the NHS, where fears over increased rationing, financial and reputationalrisks and efficiency targets shape the daily lives of clinicians as well asmanagers (Maruthappu et al, 2010).

Developing these theories in the context of health care is important as itchallenges individualistic explanations of the ‘problem of care’ in the NHS bydirecting our attention towards the organisational and institutional cultures ofhealth care and away from the ‘inner’ morals of individual practitioners. Finally,theories of demoralisation are essential in enabling us to identify not just thedistortions occurring in the relationships between health practitioners andpatients (and the potential stripping away of patients’ personhood), but also tohighlight how these distortions deny or suspend staff’s own status as moralbeings.

Acknowledgements

The study that this article draws from was funded by the School of SocialSciences at Cardiff University, as part of a doctoral studentship award. Thewriting and development of the article has been undertaken as part of aWellcome Trust postdoctoral fellowship award. Professor Joanna Latimer andProfessor Gareth Williams at Cardiff University are owed a debt of gratitude fortheir support, advice and intellectual engagement with the study that havegreatly informed the ideas in this article. I would like to thank the clinical directorand all the staff at the Emergency Department (ED) for allowing me access toobserve their work and especially to those who gave up their own timeto be interviewed. I would also like to thank the patients and families I metwhile doing fieldwork in the ED who were so generous in sharing theirexperiences and allowing me to observe their care. Finally, I am extremelygrateful to Professor Ralph Fevre for his generosity and insight in reviewing anearly draft of this article.

About the Author

Alexandra Hillman is a medical sociologist. Her work explores the relationsbetween medicine, aging, older people, care and the organisation of healthservices. She is currently working on a Wellcome trust funded fellowshipaward exploring the social and ethical aspects of dementia diagnosis.



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Institutions of care, moral proximity and demoralisation: The case of the emergency departmentThis article draws on concepts of morality and demoralisation to understand the problematic nature of relationships between staff and patients in public health services. The article uses data from a case study of a UK hospital Emergency Department to showIntroductionThe StudyThe juxtaposition of dutyCreating distance, limiting moral proximityRe-establishing proximity

DiscussionThe study that this article draws from was funded by the School of Social Sciences at Cardiff University, as part of a doctoral studentship award. The writing and development of the article has been undertaken as part of a Wellcome Trust postdoctoral fellACKNOWLEDGEMENTSAbout the AuthorA7

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